Chapter 32 My Nursing Test Banks

Wagner, High Acuity Nursing, 6e
Chapter 32

Question 1

Type: MCSA

A patient tells the nurse that there is a history of diabetes in the family and even though she has always tried to keep her blood glucose level on the low side she still developed diabetes. What information should the nurse provide?

1. Body weight is a big contributor to the development of all types of diabetes.

2. There is no way to stop the development of diabetes.

3. Diabetes can be caused by taking some medications.

4. It is thought that genetics is involved with the development of both type 1 and type 2 diabetes.

Correct Answer: 4

Rationale 1: Obesity in the presence of hereditary tendencies is a major risk factor for developing type 2 diabetes. Type I diabetes is not associated with obesity.

Rationale 2: Some risk factors for the development of diabetes can be controlled.

Rationale 3: Diabetes is not caused by medications.

Rationale 4: Type 1 diabetes seems to have a strong genetic component and is also a factor in development of type 2 diabetes.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 32-1

Question 2

Type: MCSA

A patient with acute pancreatitis asks the nurse why everyone is concerned about his blood glucose level. Which nursing response is appropriate?

1. Pancreatitis can injure the cells that produce insulin.

2. Since you are not eating, there is concern you wont have enough glucose in your system.

3. Nearly everyone with pancreatitis develops diabetes.

4. Pancreatitis requires treatment with high amounts of intravenous fluids that can increase blood glucose.

Correct Answer: 1

Rationale 1: Insulin is a polypeptide produced by the beta cells of the islets of Langerhans in the pancreas whose role is to lower the blood glucose level. An injury to the pancreas can injure these cells.

Rationale 2: This is not the reason for concern regarding this patients blood glucose.

Rationale 3: This is not a true statement.

Rationale 4: This is not the reason for monitoring this patients glucose.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 32-1

Question 3

Type: MCSA

A patient receiving an insulin injection for the first time asks the nurse how it works to reduce the blood glucose. Which of the following would be the best response for the nurse to make to the patient?

1. Insulin makes sure that fat is used as the bodys main energy source.

2. Insulin helps prevent fluid overload in the cells.

3. Insulin helps break down protein.

4. Insulin helps with cellular uptake of glucose.

Correct Answer: 4

Rationale 1: Insulin spares fat as the main energy source and makes sure that fat is not used as the main energy source.

Rationale 2: Lack of insulin results in intracellular dehydration.

Rationale 3: Insulin decreases the breakdown of protein and does not help the breakdown of protein.

Rationale 4: Under the influence of insulin, glucose is moved into cells for immediate use or stored for later use.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 32-1

Question 4

Type: MCSA

A patient with type 2 diabetes mellitus experiences a hypoglycemic reaction. The capillary blood glucose level is 60 mg/dL and the patient is given 4 ounces of orange juice. What should the nurse do next?

1. Recheck the patients blood glucose in 15 minutes.

2. Mark the medication administration record to hold the next scheduled dose of insulin.

3. Recheck the blood glucose before the next meal.

4. Give the patient another 4 ounces of orange juice in 30 minutes.

Correct Answer: 1

Rationale 1: Blood glucose levels should be tested 15 to 20 minutes after treatment has been initiated.

Rationale 2: It is unknown if the next insulin dose should be held.

Rationale 3: It may be necessary to check the blood glucose before the next meal, but it is not a good idea to wait for that check.

Rationale 4: It is not known if another administration of orange juice is indicated.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 32-2

Question 5

Type: MCSA

The nurse is preparing to administer an intravenous insulin drip to a patient admitted with diabetic ketoacidosis. Which laboratory is of most concern to the nurse?

1. Phosphorus level of 2.8 mEq/L

2. Bicarbonate level of 16 mEq/L

3. Sodium level of 130 mEq/L

4. Potassium level of 3.2 mEq/L

Correct Answer: 4

Rationale 1: The phosphorus level is within normal limits.

Rationale 2: The bicarbonate level is low, which is expected with acidosis, but it often corrects itself with insulin and IV fluid replacement.

Rationale 3: The sodium level is low but is not as critical as another option.

Rationale 4: Insulin treatment when potassium is below 3.3 mEq/L increases the risk for cardiac dysrhythmia or cardiac arrest.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 32-6

Question 6

Type: MCSA

The nurse is planning the care for a patient admitted with diabetic ketoacidosis. How does the nurse anticipate this condition will be medically managed?

1. BID dosing of NPH insulin and PRN coverage with regular insulin

2. A continuous low-dose intravenous infusion of regular insulin

3. Once-per-evening dose of Lantus insulin with daytime coverage with regular insulin

4. sliding scale coverage with regular insulin

Correct Answer: 2

Rationale 1: Twice a day dosing of NPH insulin and as needed coverage with regular insulin is frequently used to regulate patients with type 1 diabetes experiencing blood sugar fluctuations secondary to physiological stressors.

Rationale 2: A low-dose continuous source of insulin provides for stricter regulation and control of the blood sugar because dosing can be regulated hourly.

Rationale 3: Once-per-evening dose of Lantus insulin with daytime coverage of regular insulin is frequently used to regulate patients with type 1 diabetes experiencing blood sugar fluctuations secondary to physiological stressors.

Rationale 4: Sliding scale coverage with regular insulin is frequently used to regulate blood sugars in a patient with type 2 diabetes who does need a daily insulin dose but is experiencing elevated blood sugars.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 32-5

Question 7

Type: MCSA

A patient with type 1 diabetes mellitus is admitted with hyperglycemia and dehydration, and is being evaluated for diabetic ketoacidosis. The nurse recognizes that which laboratory finding would support this diagnosis?

1. Potassium of 4.5 mEq/L

2. Anion gap of 20 mEq/L

3. Sodium of 140 mEq/L

4. Bicarbonate level of 36 mmol/L

Correct Answer: 2

Rationale 1: Potassium level is within normal limits.

Rationale 2: An anion gap of greater than 17 mEq/L indicates an accumulation of unmeasured anions and would be indicative of acidosis.

Rationale 3: The sodium level is normal.

Rationale 4: A bicarbonate level of 36 is elevated, indicating metabolic alkalosis.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 32-3

Question 8

Type: MCSA

The nurse is preparing to administer an intravenous infusion containing regular insulin for a patient diagnosed with diabetic ketoacidosis. Which nursing intervention added to the patients plan of care has the highest priority?

1. Check urine for ketone bodies every shift

2. Check blood glucose levels every 2 hours

3. Monitor serum calcium levels closely

4. Adjust infusion rate according to glucose readings.

Correct Answer: 4

Rationale 1: The presence of ketones in the urine is significant, but is not an accurate method of evaluating the effectiveness of this treatment.

Rationale 2: Blood glucose levels need to be checked hourly.

Rationale 3: Serum calcium levels are important but are not the most important intervention.

Rationale 4: The most important intervention is to adjust insulin administration in response to glucose readings.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 32-6

Question 9

Type: MCSA

A patient with type 2 diabetes mellitus, lethargy, and a blood glucose level of 650 mg/dL has been diagnosed with hyperglycemic hyperosmolar syndrome. The nurse monitors this patient for the development of which complication?

1. Hyperkalemia

2. Seizures

3. Metabolic acidosis

4. Fluid volume overload

Correct Answer: 2

Rationale 1: HHS results in a substantial loss of electrolytes.

Rationale 2: HHS is associated with severe neurological changes secondary to profound dehydration.

Rationale 3: Acidosis is usually not seen with this type of diabetes because sufficient insulin is produced to prevent lipolysis and ketogenesis.

Rationale 4: HHS results is osmotic diuresis and resultant dehydration.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 32-4

Question 10

Type: MCSA

The nurse is caring for a patient with a history of type 2 diabetes who has recently experienced a myocardial infarction. The nurse would increase monitoring for findings of diabetic ketoacidosis when which medication is added to the patients drug regimen?

1. Warfarin sodium

2. Hydrochlorothiazide diuretic

3. Aspirin

4. Calcium channel blocker

Correct Answer: 2

Rationale 1: Warfarin sodium will not have any significant effect on blood glucose level.

Rationale 2: Thiazide diuretics along with the stress of the myocardial infarction may increase insulin deficit sufficiently to precipitate a hyperglycemic crisis such as DKA.

Rationale 3: Aspirin therapy should not have a significant effect on blood glucose level.

Rationale 4: Calcium channel blockers do not have any significant effects on the blood glucose level.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 32-3

Question 11

Type: MCMA

Just after being admitted to the emergency department for symptoms of influenza the patient loses consciousness. His wife reports that he is diabetic but has not taken his oral medications for a couple of days. Which nursing interventions are indicated?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Check the patients blood glucose using a finger stick monitor.

2. Place 1.5 tubes of 40% glucose gel under the patients tongue.

3. Obtain intravenous access.

4. Administer 50% dextrose subcutaneously.

5. Administer regular insulin subcutaneously.

Correct Answer: 1,3

Rationale 1: There are a number of reasons this patient may have lost consciousness including hypoglycemia. Checking the patients glucose is indicated.

Rationale 2: This patient is not conscious, so this is not an acceptable intervention.

Rationale 3: Since this patient is not conscious, it is important to secure intravenous access for administration of medications.

Rationale 4: 50% dextrose injected subcutaneously would severely damage tissues. 50% dextrose is given by intravenous infusion.

Rationale 5: This patient is more likely to have hypoglycemia due to illness even though he has not been taking his medications. Additional insulin is not indicated.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 32-2

Question 12

Type: MCSA

A patient with type 2 diabetes reports that she can always tell when her blood sugar is low because my fingers tingle. How should the nurse interpret this information?

1. This is a central nervous system effect of hypoglycemia.

2. The patient is experiencing increased blood glucose rather than decreased blood glucose.

3. This patient is developing hypoglycemia unawareness.

4. This is a common catecholamine effect of hypoglycemia.

Correct Answer: 4

Rationale 1: This symptom is not a nervous system effect of hypoglycemia.

Rationale 2: There is no indication that the patient is experiencing hyperglycemia.

Rationale 3: The patient is aware of how her body responds to hypoglycemia. This is not hypoglycemia unawareness.

Rationale 4: Tingling fingers is a finding caused by increased levels of catecholamines.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 32-2

Question 13

Type: MCMA

A patient with long-standing type 2 diabetes may be developing diabetic ketoacidosis. Which assessment findings would the nurse evaluate as supporting that diagnosis?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. A sweet smell to the breath

2. Ketonuria

3. Blood pH of 7.48

4. WBC of 28,000

5. Potassium of 3.4 mEq/L

Correct Answer: 1,2,4,5

Rationale 1: Acetone is excreted through the lungs due to production of acidic ketone bodies. This causes ketone breath.

Rationale 2: Presence of ketones in the urine, or ketonuria, is associated with diabetic ketoacidosis.

Rationale 3: Blood pH of 7.48 would indicate the patient is alkalotic, not acidotic.

Rationale 4: A WBC this high indicates infection, but this level would also occur with DKA. DKA is often caused by infection.

Rationale 5: Low potassium occurs in DKA.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 32-3

Question 14

Type: MCMA

A patient is brought to the emergency department by her son who reports that she was recently diagnosed with diabetes and is not acting like herself today. Which additional findings would the nurse consider as suggesting hyperglycemic hyperosmolar state?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. The son reports his mothers diabetes is type 2.

2. The patients plasma glucose reading is 638 mg/dL.

3. The patients bicarbonate level is 14.

4. The patients blood pH is 7.28.

5. The patient is 60 years of age.

Correct Answer: 1,2,5

Rationale 1: HHS is more common in patients with type 2 diabetes.

Rationale 2: Very high serum glucose levels are associated with HHS.

Rationale 3: Low bicarbonate levels are associated with DKA.

Rationale 4: Acidosis in often not present in HHS.

Rationale 5: HHS is seen in older patients, while DKA typically occurs in those younger than 44.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 32-4

Question 15

Type: MCMA

A patient diagnosed with hyperglycemic hyperosmotic syndrome (HHS) will be started on rehydration fluids. How will the nurse anticipate managing this treatment?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Initial treatment will be with rapidly infused lactated Ringers solution.

2. Once the patients blood glucose has decreased to around 200 mg/dL a glucose containing solution will be used for the remaining hydration.

3. The patient will be encouraged to drink as much fluid as possible.

4. The nurse will monitor the patients lungs for signs of overload.

5. The fluid used for resuscitation will contain insulin.

Correct Answer: 2,4

Rationale 1: Lactated Ringers solution will not be used for this patients fluid resuscitation.

Rationale 2: In order to prevent hypoglycemia as the blood glucose approaches normal, the original fluid used for resuscitation is changed to a fluid containing glucose.

Rationale 3: The patient will be held NPO until the crisis state is resolved.

Rationale 4: This rapid fluid resuscitation places the patient at risk for fluid overload. The nurse should conduct careful assessment for this complication.

Rationale 5: The patient will receive intravenous insulin by infusion, but this fluid will not be used for fluid resuscitation.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 32-5

Question 16

Type: MCSA

Despite the inherent risks, the patient with diabetic ketoacidosis will be given sodium bicarbonate to reverse severe metabolic acidosis. How does the nurse expect to administer this medication?

1. In enema form

2. As a 50 mL bolus injection intravenously

3. Along with potassium chloride

4. Over at least an 8-hour period

Correct Answer: 3

Rationale 1: Sodium bicarbonate is not administered by enema.

Rationale 2: Sodium bicarbonate is not given as a bolus in this application.

Rationale 3: This sodium bicarbonate will be given in a water solution along with 20 mEq of potassium chloride.

Rationale 4: It is recommended that the standard dose of 100 mmol be given over a 2-hour period.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 32-5

Question 17

Type: MCSA

A patient will receive insulin as treatment for diabetic ketoacidosis. The patient weighs 225 pounds and has a pretreatment serum glucose of 288 mg/dL. Which prescription would the nurse be comfortable administering?

1. Administer regular insulin 102 units/hr by intravenous infusion.

2. Administer NPH insulin 20 units twice daily.

3. Administer regular insulin intravenously at 10 units/hr.

4. Administer regular insulin 100 units in 1000 mL NS at 28.8 mL/hr.

Correct Answer: 3

Rationale 1: This patient weighs approximately 102 kg. An infusion at 100 unit/hr is too high.

Rationale 2: NPH insulin is a slowly acting insulin and would not be used for this treatment.

Rationale 3: The recommended insulin dose is 0.1 unit/kg/hr. This patient weighs 102 kg. 102 0.1 unit = 10.2. The nurse would be comfortable administering a dose within 0.2 units of recommended.

Rationale 4: The patients pretreatment blood glucose is not used as a component of the recommended dose of insulin.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 32-5

Question 18

Type: MCMA

The nurse comes to the cardiac patients room to administer subcutaneous insulin. The patient says, I have always taken pills for my diabetes. Am I getting worse? What should the nurse consider when formulating a response to this question?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Some cardiac diseases cause oral antidiabetic medications to be less effective.

2. The stress of illness makes it difficult to control glucose with oral medications.

3. The changes associated with hospitalization make it difficult to control glucose with oral medications.

4. The patient will likely need to take insulin to control glucose even after release from the hospital.

5. Once discharged the patient can use urine dipstick measurements to guide insulin therapy.

Correct Answer: 2,3

Rationale 1: There is no truth to this statement.

Rationale 2: Often patients with type 2 diabetes require insulin while acutely ill.

Rationale 3: While hospitalized, the patient is under additional stress and may not eat or exercise as at home. These changes may make it necessary to use insulin for glucose control.

Rationale 4: Generally once patients are discharged to home, they can control their glucose with oral medications.

Rationale 5: It is recommended that blood glucose rather than urine glucose measurements be used to guide therapy.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 32-6

Question 19

Type: MCSA

A patient with diabetic retinopathy is admitted to the intensive care unit. Which nursing interventions are indicated?

1. Keep the room light dimmed.

2. Provide a braille board for communication.

3. Offer frequent reorientation to the environment.

4. Limit visitors to immediate family only.

Correct Answer: 3

Rationale 1: Dimming the room lights may make it more difficult for the patient to identify unfamiliar objects.

Rationale 2: The patient has difficulty seeing, but there is no indication that the patient cannot communicate.

Rationale 3: When patients cannot see, they may become confused in unfamiliar environments. Frequent reorientation is helpful.

Rationale 4: There is no reason to limit this patients visitors to immediate family only.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 32-7

Question 20

Type: MCSA

The patient with diabetic neuropathy has been admitted to the intensive care unit after major abdominal surgery. Which nursing intervention is indicated because of this neuropathy?

1. Keep the skin clean and dry.

2. Place the arms and legs in the patients position of comfort.

3. Instruct the patient to cough and take deep breaths every 2 hours.

4. Place a warming blanket under the patient to prevent hypothermia.

Correct Answer: 1

Rationale 1: The patient with neuropathy has high risk for skin breakdown. Keeping the skin clean and dry helps prevent breakdown.

Rationale 2: The position of comfort may not be the best position for the patients limbs.

Rationale 3: Coughing and deep breathing will help prevent pneumonia, but will not protect skin integrity.

Rationale 4: A patient with neuropathy or who is unable to move himself should not be in contact with a warming device. Burns may occur because the patient cannot feel the excessive heat or because the patient cannot move away from this heat.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 32-7

Wagner, High Acuity Nursing, 6/E Test Bank

Copyright 2014 by Pearson Education, Inc.

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